HomeMy WebLinkAboutG-18-6084 i _ MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
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= 1 ` CITY Yarmouth MA DATE 4127118 PERMIT# /x'-+46 a--0060
JOBSITE ADDRESS 82 Higgins Crowell Road 'OWNER'S NAME Legatowicz
G ' OWNER ADDRESS do Oceanside Restoration TEL 508-771-3110 IFAX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL 0 RESIDENTIALQ
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CLEARLY NEW:❑ RENOVATION:0 REPLACEMENT:❑ PLANS SUBMITTED: YESD NO❑
APPLIANCES 7 FLOORS-. BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BOILER . 1
BOOSTER � - r
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CONVERSION BURNER r is ii r if i. 1
COOK STOVE
DIRECT VENT HEATER j; [ i ,
DRYERr
FIREPLACE � I 1 1
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FRYOLATOR , ii� �j
FURNACE1 MUNI i
FURNACE -1,
GENERATOR
GRILLE
INFRARED HEATER
LABORATORY COCKS
MAKEUP AIR UNIT
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UNVENTED ROOM HEATER •, j t_'uLo� ( ; nr ��.-. ,r,r
WATER HEATER I j
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INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES ❑. NO ❑
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABIUTY INSURANCE POLICY Q OTHER TYPE INDEMNITY ❑ BOND 0
OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the Insurance coverage required by Chapter 142 of the
Massachusetts General Laws,and that my signature on this permit application waives this requirement.
CHECK ONE ONLY: OWNER ❑ AGENT ❑
SIGNATURE OF OWNER OR AGENT
I hereby certify that all of the details and information I have submitted or entered regarding this application are true and accurate to the best of my knowledge
and that all plumbing work and installations perfomned under the permit issued for this application will be in compliance with all Pertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER-GASFITTER NAME Stephen D.Ewing LICENSE# 15281 SIGNATURE
MP 0 MGF❑ JP❑ JGF❑ LPGI❑ CORPORATION 011 3672 PARTNERSHIP❑# LLC❑#
COMPANY NAME: Edgewater Plumbing&Heating I ADDRESS P.O.Box 656
CITY Sagamore STATE MA ZIP 02561 TEL 508-317-9680
FAX CELL 508-737-0077 EMAIL steve@edgewaterplumbinginc.com
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